Acute leukaemia in acromegaly patients

Acromegaly patients are known to have an increased risk of malignancies, especially colonic adenocarcinoma. This may be as a result of the growth-stimulating effect of growth hormone (GH). The clustering of leukaemia in children treated with GH has also caused concern. There have been a few reports of leukaemia in acromegaly patients. We report two patients with acute lymphoblastic leukaemia and one patient with acute myeloid leukaemia among 106 acromegaly patients treated over a 15-year period. Two of the cases received radiotherapy as part of their treatment. Adjusted for age and follow-up years, the incidence of leukaemia in this cohort is significantly higher than the general population. The incidence is also higher than would be expected as a result of radiotherapy alone, suggesting that GH may play a synergistic role.

Treatment of Chinese acromegaly with a combination of bromocriptine and octreotide

BACKGROUND

Good results have been reported with combined use of octreotide and bromocriptine in acromegalic Caucasians. Data concerning the efficacy and tolerability of this combination treatment in Chinese acromegalic patients are scanty.

AIM

The aim of this study was to assess the efficacy and tolerability of combined therapy using bromocriptine and octreotide in the treatment of acromegaly in Chinese patients and to compare the cost-effectiveness of various regimes.

METHODS

Sixteen Chinese acromegalic patients with growth hormone (GH) concentration not suppressible to below 5 mU/L (2 microg/L) during an extended OGTT were recruited to undergo four phases of the study. During the study period, the patients were given bromocriptine alone, bromocriptine and low dose octreotide, bromocriptine and medium dose octreotide, and medium dose octreotide alone. Plasma concentrations of GH and insulin-like growth factor-1 (IGF-1) were measured before and after the completion of each phase.

RESULTS

The number of patients reaching target GH concentrations was significantly higher when treated with octreotide compared to baseline (p<0.05). Bromocriptine alone had a significant effect but not to the extent of octreotide alone. A combination of low dose octreotide and bromocriptine is as efficacious in the treatment of acromegaly as high dose octreotide. None of the patients suffered from serious adverse effects.

CONCLUSION

The results confirmed the usefulness and tolerability of bromocriptine and octreotide in Chinese acromegalics. The most cost-effective regime in this study was a combination of low dose octreotide and bromocriptine.

Obesity is the key determinant of cardiovascular risk factors in the Hong Kong Chinese population: cross-sectional clinic-based study

OBJECTIVES

To examine the interrelationships between obesity and various cardiovascular risk factors, and to investigate the relative importance of insulin and obesity in their associations with various pathophysiologies.

DESIGN

Cross-sectional clinic-based study.

SETTING

Medical clinics at a university teaching hospital, Shatin, Hong Kong.

PARTICIPANTS

A heterogeneous cohort of 767 Hong Kong Chinese subjects with a mean age of 43 (standard deviation, 14) years.

MAIN OUTCOME MEASURES

Body mass index, waist circumference, plasma insulin, insulin resistance index, fasting plasma glucose and lipid levels, blood pressure, and 24-hour urinary albumin excretion.

RESULTS

Pathophysiological abnormalities and risk factors are frequently clustered to varying degrees. Compared with the control subjects, patients with at least one component of the metabolic syndrome were more obese, hyperinsulinaemic, insulin resistant, hyperglycaemic, hypertensive, dyslipidaemic, and albuminuric (all variables, P<0.001). Increasing degrees of body mass index, waist circumference, plasma insulin level, and insulin resistance index were associated with an increasing number of risk factors after adjusting for age and sex (all variables, P<0.02). Multiple regression analysis showed that obesity, as reflected by either the body mass index or waist circumference, had a closer association than plasma insulin with the fasting plasma glucose concentration, blood pressure, and high-density lipoprotein-cholesterol and triglyceride concentrations. Using 19.0-20.9 kg/m(2) as the reference body mass index interval, the lowest cardiovascular risk was associated with a body mass index of <23.0 kg/m(2). There was an increased risk of 3.1 and 5 times when the body mass index was 23. 0-24.9 kg/m(2) and > or =25 kg/m(2), respectively.

CONCLUSIONS

Obesity, hyperinsulinaemia, and insulin resistance are characteristic features of Hong Kong Chinese patients who have various components of the metabolic syndrome. Obesity has a greater effect than plasma insulin on various pathophysiologies.

Glycaemic control in type 2 diabetes: the impact of body weight, beta-cell function and patient education

We examined the determinants of glycaemic control in a consecutive cohort of 562 newly-referred Chinese type 2 diabetic patients (57% women) during a 12-month period. All patients underwent a structured assessment with documentation of clinical and biochemical characteristics. Pancreatic beta-cell function was assessed by fasting plasma C-peptide concentration. Insulin deficiency was defined as fasting plasma C-peptide <0.2 pmol/ml. Insulin resistance (IR) was calculated using the homeostasis model assessment (HOMA) based on a product of fasting plasma glucose and insulin concentrations. Treatment was considered appropriate when insulin-deficient patients were treated with insulin and non-insulin-deficient patients were treated with oral agents or diet. Mean (+/-SD) age was 54.3+/-13.8 years (range 17-87 years) and disease duration was 5.0+/-5.9 years. At the time of referral, 70.5% (n=396) were on drug therapy (9% on insulin and 62.8% on oral agents), 20.6% (n=116) were on diet and 9% (n=50) had not received any form of treatment. The mean HbA(lc) was 8.4+/-2.3%. The geometric mean (x// antilog SD) of IR was 4.62x//2.51 (range 0. 63-162.7) and correlated only with waist : hip ratio (WHR, p=0.008). The geometric mean of plasma C peptide was 0.47x//2.89 nmol/l and correlated with BMI (p<0.001). Glycated haemoglobin was correlated positively with age (p=0.013), disease duration (p<0.001), IR (p<0. 001) and negatively with BMI (p<0.001). Glycated haemoglobin was lower in patients who had seen a dietitian (7.9% vs. 8.7%, p<0.001) or diabetes nurse (7.8% vs. 8.7%, p<0.001) or who performed self blood glucose monitoring (7.9% vs. 8.6%, p=0.001) and higher among smokers (8.9% vs. 8.2%, p=0.003). Compared to insulin-deficient patients (n=118), non-insulin-deficient patients (n=413) had features resembling that of the Metabolic Syndrome with increased WHR (p=0.005), blood pressure (p<0.001), BMI (p=0.001) and were older (p=0.04). Amongst the insulin-deficient patients, 27% were treated with oral agents or diet. Patients receiving appropriate therapy (n=362) had a lower HbA(lc) than those treated inappropriately (n=173) (8.2% vs. 8.7%, p=0.02). On multivariate analysis, short disease duration (p<0.001), low IR (p<0.001), high BMI (p=0.001), diabetes education (p<0.001), lack of smoking (p=0. 014) and choice of appropriate treatment (p=0.009) were the independent determinants of good glycaemic control.

Diagnosing diabetes mellitus in the Asian population

Western guidelines have been used to diagnose diabetes mellitus in Asia. The increased availability of data from Asian populations, however, has made it apparent that modifications to western guidelines are needed when they are used in Asia. Both the American Diabetes Association and the World Health Organization have recently modified their diagnostic criteria for diabetes mellitus. The implications of these new criteria in Asia are discussed in this paper. The significance of using fasting plasma glucose measurements and/or oral glucose tolerance tests in the diagnosis of diabetes mellitus is analysed. A simple approach to diagnose diabetes mellitus in the Hong Kong Chinese population is also suggested.

Long-term effects of angiotensin-converting enzyme inhibition and metabolic control in hypertensive type 2 diabetic patients

Long-term effects of angiotensin-converting enzyme inhibition and metabolic control in hypertensive type 2 diabetic patients.

BACKGROUND

In hypertensive type 2 diabetic patients, treatment with angiotensin-converting enzyme (ACE) inhibitors is associated with a lower incidence of cardiovascular events than those treated with calcium channel-blocking agents. However, the long-term renal effects of ACE inhibitors in these patients remain inconclusive. In 1989, we commenced a placebo-controlled, double-blind, randomized study to examine the anti-albuminuric effects of enalapril versus nifedipine (slow release) in 102 hypertensive, type 2 diabetic patients. These patients have been followed up for a mean trial duration of 5.5 +/- 2.2 years. We examined the determinants, including the effect of ACE inhibition on clinical outcomes in these patients.

METHODS

After a six-week placebo-controlled, run-in period, 52 patients were randomized double-blind to receive nifedipine (slow release) and 50 patients to receive enalapril. After the one-year analysis, which confirmed the superior anti-albuminuric effects of enalapril (-54%) over nifedipine (+11%), all patients were continued on their previously assigned treatment with informed consent. They were subdivided into normoalbuminuric (N = 43), microalbuminuric (N = 34), and macroalbuminuric (N = 25) groups based on two of three 24-hour urinary albumin excretion (UAE) measurements during the run-in period. Renal function was shown by the 24-hour UAE, creatinine clearance (CCr), and the regression coefficient of the yearly plasma creatinine reciprocal (beta-1/Cr). Clinical endpoints were defined as death, cardiovascular events, and/or renal events (need for renal replacement therapy or doubling of baseline plasma creatinine).

RESULTS

In the whole group, patients treated with enalapril were more likely to revert to being normoalbuminuric (23.8 vs. 15.4%), and fewer of them developed macroalbuminuria (19.1 vs. 30.8%) compared with the nifedipine-treated patients (P < 0.05). In the microalbuminuric group, treatment with enalapril (N = 21) was associated with a 13.0% (P < 0.01) reduction in 24-hour UAE compared with a 17.3% increase in the nifedipine group (N = 13). In the macroalbuminuric patients, enalapril treatment (N = 11) was associated with stabilization compared with a decline in renal function in the nifedipine group, as shown by the beta-1/Cr (0.65 +/- 4.29 vs. -1.93 +/- 2.35 1/micromol x 10-3, P < 0.05) after adjustment for baseline values. Compared with the normoalbuminuric and microalbuminuric patients, those with macroalbuminuria had the lowest mean CCr (75.5 +/- 24.1 vs. 63.5 +/- 21.3 vs. 41.9 +/- 18.5 mL/min, P < 0.001) and the highest frequency of clinical events (4.7 vs. 5.9 vs. 52%, P < 0. 001). On multivariate analysis, beta-1/Cr (R2 = 0.195, P < 0.001) was independently associated with baseline HbA1c (beta = -0.285, P = 0.004), whereas clinical outcomes (R2 = 0.176, P < 0.001) were independently related to the mean low-density lipoprotein cholesterol (beta = 2.426, P = 0.018), high-density lipoprotein cholesterol (beta = -8.797, P = 0.03), baseline UAE (beta = 0.002, P = 0.04), and mean CCr during treatment (beta = -0.211, P = 0.006).

CONCLUSION

In this prospective cohort analysis involving 102 hypertensive, type 2 diabetic patients with varying degrees of albuminuria followed up for a mean duration of five years, we observed the importance of good metabolic and blood pressure control on the progression of albuminuria and renal function. Treatment with enalapril was associated with a greater reduction in albuminuria than with nifedipine in the entire patient group, and especially in those with microalbuminuria. In the macroalbuminuric patients, the rate of deterioration in renal function was also attenuated by treatment with enalapril.

Glucose intolerance and other cardiovascular risk factors in chinese women with a history of gestational diabetes mellitus

Women with a history of gestational diabetes (GDM) are at increased risk of developing diabetes compared with other women. There are few data on associations between GDM and cardiovascular risk factors. Between 1988 and 1995, 801 Chinese women with a history of GDM were recruited for a 75g oral glucose tolerance test (OGTT) and assessment of various cardiovascular risk factors, namely obesity, hypertension and dyslipidaemia, 6 weeks after delivery at the Diabetes Centre of the Prince of Wales Hospital. Another 431 women with no past history of diabetes or GDM recruited in a diabetes prevalence study were used as control subjects. After adjustment for age, body mass index and smoking, the prevalence of glucose intolerance remained higher in women with a history of GDM when compared to normal controls. The relative risks of obesity, hypertension, dyslipidaemia, diabetes and impaired glucose tolerance in women with a history of GDM comparing to normal subjects were, respectively, 2.4, 7.5, 2.4, 8.1 and 5.0. After excluding those with abnormal glucose tolerance, subjects with a history of GDM still had more adverse cardiovascular risk factors, including higher blood pressure, glycaemic and lipid parameters, than control subjects (after adjustment for age, body mass index and smoking). In conclusion, compared with normal subjects, Chinese women with a history of GDM had an 8-fold increased risk of having diabetes based on their OGTTs performed 6 weeks postdelivery. These women also have increased rates of other cardiovascular risk factors including obesity, high blood pressure and dyslipidaemia.

Prediction of hypertension, diabetes, dyslipidaemia or albuminuria using simple anthropometric indexes in Hong Kong Chinese

OBJECTIVE

It is important to determine what values of simple anthropometric measurements are associated with the presence of adverse cardiovascular risk factors such as diabetes or hypertension to provide an indication for further detailed investigations. In this analysis, we aimed to assess which anthropometric cutoff values are best at predicting the likelihood of diabetes, hypertension, dyslipidaemia and albuminuria in Hong Kong Chinese.

DESIGN AND SETTING

The data were obtained from a previously reported prevalence survey for glucose intolerance in a representative Hong Kong Chinese working population.

SUBJECTS

1513 subjects (910 men and 603 women) with mean age+/-s.d. 37.5+/-9.2 y.

MEASUREMENTS

We examined the likelihood ratios of having diabetes, hypertension, dyslipidaemia and albuminuria in subjects with various cutoff values of the four simple anthropometric indexes, namely, body mass index, waist-hip ratio, waist circumference and the ratio of waist-to-height.

RESULTS

We developed a nomogram to show the predictive values of different indexes for the cardiovascular risk factors using likelihood ratio analysis. Using Caucasian mean levels of the simple anthropometric indexes to predict diabetes or hypertension in Hong Kong Chinese gave a high likelihood ratio of 2:3:5.

CONCLUSION

Higher levels of body mass index, waist-hip ratio, waist circumference and the ratio of waist-to-height are associated with risk of having diabetes mellitus or hypertension in Hong Kong Chinese as in Caucasians. However, the cutoff values of those anthropometric indexes to define obesity used in Caucasians may not be applicable to Chinese.

Plasma insulin, growth hormone, cortisol, and central obesity among young Chinese type 2 diabetic patients

OBJECTIVE

To examine the relationships between central obesity, insulin resistance index, plasma insulin, growth hormone (GH), and cortisol concentrations in 90 young Chinese type 2 diabetic patients (aged 33+/-5 years) and 104 age- and sex-matched control subjects (aged 32+/-9 years).

RESEARCH DESIGN AND METHODS

Young Chinese diabetic patients (aged <40 years) were recruited from the Prince of Wales Hospital. Blood pressure, height, weight, and waist and hip circumferences were determined. Venous blood was sampled for measurements of fasting plasma glucose, HbA1c, lipids, creatinine, insulin, GH, and cortisol. A 24-h urine was assayed for urinary albumin excretion (UAE). General and central obesity was represented by BMI and waist circumference, respectively. Insulin resistance index was estimated as a product of fasting plasma insulin and glucose concentrations.

RESULTS

Compared with control subjects, diabetic patients were more obese, hyperglycemic, and had worse lipid profile, higher blood pressures, UAE, insulin resistance index, plasma insulin, and cortisol concentrations (all P < 0.001) but lower GH concentrations (P < 0.05). When analyzed as a whole group (n = 194), increasing quartiles of waist circumference were associated with increasing trends of insulin resistance index, plasma insulin, and cortisol concentrations (all P < 0.01) but a decreasing trend of plasma GH concentration (P < 0.05). Using stepwise multiple regression analysis, waist circumference was only associated with sex variable (being higher in men) in the control subjects. In the diabetic group, 51% of waist circumference was independently related to male sex and increased plasma insulin and cortisol concentrations as well as reduced plasma GH levels.

CONCLUSIONS

In young Chinese type 2 diabetic patients, hyperinsulinemia, hypercortisolemia, and reduced plasma GH levels were closely associated with central obesity. Based on these findings, we postulate that maladaptive hormonal responses to rapid changes in lifestyle may have led to obesity and type 2 diabetes in these young patients. Alternatively, lifestyle-related obesity may have given rise to these hormonal changes. More studies are required to delineate the nature of these relationships.

Diabetic microangiopathic complications in young Chinese diabetic patients: a clinic-based cross-sectional study

Microangiopathic complications are major causes of morbidity and mortality in diabetic patients. We studied 150 consecutive young Chinese diabetic subjects attending the Prince of Wales Hospital Diabetes Center on their presence of diabetic microangiopathic complications and the relationships with other risk factors. All patients with aged younger than 40 years and had an age of onset of disease at younger than 35 years. Their known duration of diabetes was 57.2 +/- 5.0 months. Of these 150 patients, 50 (33.3%) had microangiopathic complications, 34 (22.7%) had albuminuria, 11 (7. 3%) had peripheral neuropathy, and 21 (14%) had retinopathy. Using multiple logistic regression analysis, albuminuria was independently associated with body-mass index and systolic blood pressure, peripheral neuropathy was associated with fasting plasma glucose and lower high-density lipoprotein cholesterol, and retinopathy was associated with duration of disease and fasting plasma glucose. In conclusion, there were high percentages of microangiopathic complications, particularly albuminuria, in our young Chinese diabetic patients. Obesity, high blood pressure, and poor glycemic control are important for these complications.

Gastrointestinal symptoms in Chinese patients with Type 2 diabetes mellitus

AIMS

To examine and compare gastrointestinal (GI) symptoms in Hong Kong Chinese Type 2 diabetic outpatients and non-diabetic control subjects.

METHODS

A total of 149 Chinese Type 2 diabetic patients (66 men and 83 women, age (mean +/- SD) 46.8+/-11.1 years) newly referred to the diabetes clinic of the Prince of Wales Hospital, Hong Kong were examined. Sixty-five age and sex-matched non-diabetic subjects were recruited from the community as controls (22 men and 43 women, age (mean +/- SD) 46.5+/-6.6 years, P = 0.820). All patients were interviewed regarding GI symptoms over the past year, using a questionnaire that covered 14 items. A scoring system from 0 to 4 was used to grade severity.

RESULTS

Diabetic patients had higher blood pressure, fasting plasma glucose and glycated haemoglobin and were more often smokers than control subjects. Of the 149 diabetic subjects, 105 (70.5+/-45.8%) had GI symptoms while only 20 (30.8%) of the 65 control subjects had GI symptoms (P<0.001). The respective percentages of upper and lower GI symptoms in diabetic and normal subjects were 44.3% vs. 24.6% (P = 0.006) and 54.4% vs. 13.9% (P<0.001). The three commonest GI symptoms in diabetic patients were diarrhoea (34.9%), constipation (27.5%) and epigastric fullness (16.8%). After adjustment for age, sex, duration of diagnosed diabetes and smoking, patients with or without metformin had similar percentages or scores for GI symptoms. On multivariate analysis using age, body mass index, fasting plasma glucose, glycated haemoglobin, duration of diagnosed diabetes and presence of peripheral neuropathy as independent variables, duration of diabetes was the only independent parameter associated with total score for GI symptoms (beta = 0.116, P = 0.003), for upper GI symptoms (beta = 0.073, P = 0.005) and for lower GI symptom (beta = 0.043, P = 0.020).

CONCLUSIONS

Up to 70% of the Chinese Type 2 diabetic outpatients have GI symptoms, which is a much higher rate than in non-diabetic control subjects. Duration of diabetes is the most important factor associated with the presence of such GI symptoms.

Ten-year cardiovascular risk in a Hong Kong population

BACKGROUND

Cardiovascular disease is a major health issue in Hong Kong. We conducted a screening program to assess the 10-year risk for the population and to assess the potential benefit of large-scale screening in Hong Kong.

METHOD

A local screening program for cardiovascular risk was carried out in a health service network with a total of 17,716 participants. Retrospective data analysis for the prevalence and distribution of the various risk factors was performed. The data were then applied to calculate the 10-year risk of each individual, according to the European Task Force coronary risk chart.

RESULTS

Of the participants, 54.2% had total cholesterol levels > 5.2 mmol/l; 28.7% had body mass index > 25 kg/m2; 18.5% were hypertensive; 15.1% were smokers; and 3.7% had diabetes mellitus. There were 35.5% of the screened population who had at least two risk factors and 10.9% had at least three risk factors. A total of 9049 individuals satisfied the criteria for the European Task Force guidelines and were selected for 10-year cardiovascular risk analysis. We calculated that 68.0% of the male population had at least 10% risk and 41.5% had at least 20% risk of developing a coronary heart event within 10 years. Among women, 48.2% of the population carried at least 10% risk and 2.8% carried at least 20% risk.

CONCLUSION

The calculated 10-year risk of the population, particularly for men, is significant. Our study demonstrated that mass screening is feasible, and has the benefit of early identification of high-risk individuals, which could be a reasonable strategy for cost-effective medicine.

Clinical characteristics of acromegaly in Hong Kong

This study analyses the clinical characteristics of acromegalic patients in Hong Kong. All patients with acromegaly under follow up in Prince of Wales Hospital, Hong Kong between January 1984 and December 1992 were reviewed retrospectively. Detailed hospital notes were available for review in 28 out of 34. Of the 28 patients with full records available, 27 were Chinese and 1 was Nepalese. There were 8 (28.6%) males and 20 (71.4%) females. The mean age (+/- SD) at presentation was 51.2+/-16.8 years (range: 28 to 84 years) (male, 49.9+/-13.9 years [range: 28-66]; female, 51.7+/-18.1 years [range: 31-84]; p-value: NS). The commonest mode of presentation (n=22, 78.6%) was clinical suspicion by medical staff during consultation for other conditions, acromegaly being later confirmed. The estimated duration of symptoms, before diagnosis, was 14 years (range: 1 to 30 years). CT scan imaging of the pituitary gland showed that 12 patients (42.9%) had pituitary macro-adenomas (> or =1 cm), 3 (10.7%) had micro-adenomas (<1 cm), 6 (21.4%) had normal imaging, 1 (3.6%) had an empty sella and 6 (21.4%) had suspicious but inconclusive lesions in the pituitary gland. Surgery was offered as initial treatment to all patients. 4 to 6 weeks after surgery, if the maximal growth hormone response following glucose loading exceeded 10 microg/L, radiotherapy was offered. Of the 28 patients, 13 received surgery and radiotherapy, 2 surgery only, 4 radiotherapy only, 4 no treatment and 5 defaulted. At presentation, 50% had some abnormality of glucose tolerance. The mean early morning fasting baseline growth hormone was 52.8+/-37.0 microg/L (mean +/- SD, median: 48.1 microg/L) and the maximal growth hormone response during an extended oral glucose tolerance test was 63.2+/-34.9 microg/L (median: 61.3 microg/L). Forty five percents of patients had a maximal growth hormone response exceeding 60 microg/L. Of the 19 patients who underwent surgery and/or radiotherapy, 15 had their pituitary function reassessed 6 months after intervention. Their early morning fasting growth hormone and maximal growth hormone response in an extended oral glucose tolerance test were 21.3+/-25.8 and 35.4+/-37.5 microg/L, respectively. In conclusion, acromegaly in Hong Kong has an estimated annual incidence of 3.8 per million. There is a female preponderance, tendency to late presentation (>10 years) and low number of large tumors. Up to 80% were referred following observer suspicion.

Age, body mass index and 2-hour plasma glucose are the major determinants of blood pressure in Chinese women newly diagnosed to have glucose intolerance

Hypertension and diabetes frequently coexist and greatly increase cardiovascular risk. There are relatively few data on the relationship between blood pressure and plasma glucose in newly diagnosed diabetic subjects especially in Chinese. We examined the glycaemic status, blood pressure profiles and other clinical and biochemical characteristics in 1298 Hong Kong Chinese women. These women were referred to the Diabetes and Endocrine Center of the Prince of Wales Hospital for screening of diabetes. The reasons for referral included a positive family history of diabetes or a history of gestational diabetes. Of the 1298 subjects, 836 (64.4%) had normal oral glucose tolerance test, 284 (21.9%) had impaired glucose tolerance and 178 (13.7%) had diabetes. Compared to non-diabetic subjects, the odds ratio (95% confidence interval) of having hypertension in subjects with impaired glucose tolerance or diabetes were 2.83 (1.90, 4.23) (P<0.001) and 5.94 (3.94, 8.96) (P<0.001), respectively. When analyzed as a continuous variable by age-adjusted partial correlation coefficients, systolic blood pressure was correlated with body mass index, fasting and 2-h plasma glucose, while diastolic blood pressure was correlated with body mass index. Using age, body mass index, fasting and 2-h plasma glucose, glycated hemoglobin, cholesterol, triglyceride and smoking as independent variables in multivariate analysis, hypertension was independently related to age, body mass index and 2-h plasma glucose. In conclusion, increased blood pressure was common in Hong Kong Chinese women who were newly diagnosed to have glucose intolerance. Apart from age and body mass index, plasma glucose was an independent determinant for blood pressure in these subjects.

Use of the 1997 American Diabetes Association diagnostic criteria for diabetes in a Hong Kong Chinese population

OBJECTIVE

Recently, the American Diabetes Association (ADA) has proposed revised diagnostic criteria for diabetes. Lowering of the fasting plasma glucose (FPG) cutoff value is intended to reduce the discrepancy with the 2-h plasma glucose (PG) cutoff value and to encourage the use of FPG. We have applied these new criteria to data collected from a population-based prevalence survey in Hong Kong Chinese subjects of working age.

RESEARCH DESIGN AND METHODS

The results of 1,513 oral glucose tolerance tests (OGTTs) from a previously published prevalence survey of glucose intolerance and cardiovascular risk factors in a Hong Kong Chinese working population were reexamined using the new criteria. Of the 1,513 subjects, 27 had a known history of diabetes. Of the remaining 1,486 subjects, 228 were also selected randomly for a second OGTT without prior knowledge of the result of the first test.

RESULTS

After exclusion of the 27 subjects with a known history of diabetes, the crude prevalence of diabetes was 2.83% (n = 42) when the World Health Organization's (WHO) criteria were applied. When the criterion of FPG > or = 7.0 mmol/l was used, as recommended by the ADA, the prevalence of diabetes was 1.41% (n = 21). Twenty-nine subjects (1.95%) with FPG < 7.0 mmol/l had a 2-h PG > or = 11.1 mmol/l. Eight subjects (0.53%), previously without a diagnosis of diabetes according to the WHO criteria (FPG < 7.8 mmol/l and 2-h PG < 11.1 mmol/l), had FPG between 7.0 and 7.8 mmol/l and were classified as having diabetes by the ADA criteria. This classification gave a net change of -1.42% in the prevalence of diabetes between the use of FPG > or = 7.0 mmol/l alone and the use of WHO criteria. Among the 1,486 subjects with no known history of diabetes, those classified as having diabetes according to the ADA FPG criterion alone had higher HbA1c and fructosamine levels than diabetic subjects defined by the WHO criteria. Of the 228 subjects for whom two FPG measurements were available, those who had consistent definitions (diabetes, impaired fasting glucose, normal fasting glucose) on both occasions were considered to have reproducible tests, giving an overall reproducibility of 90.8% (207 of 228).

CONCLUSIONS

Compared with the WHO criteria, the use of FPG to diagnose diabetes, as recommended by the ADA, was a more reproducible test and identified those subjects who had a greater degree of hyperglycemia. Although lowering of the cutoff value from 7.8 to 7.0 mmol/l increased the number of diagnoses among subjects with low FPG, the omission of the 2-h PG would lead to fewer subjects having their diabetes diagnosed.

Antibodies to glutamic acid decarboxylase in young Chinese diabetic patients

Antibodies to glutamic acid decarboxylase (GAD) are a useful autoimmune marker for type 1 diabetes mellitus in Caucasians. We examined antibodies to GAD and their relationships with clinical features and pancreatic beta cell function in 140 young Chinese diabetic patients. Over an 18-month period beginning in 1995, 140 young Chinese diabetic subjects with age of onset of disease < or = 35 years and age < 40 years were recruited consecutively, irrespective of their modes of presentation. Clinical features, antibodies to GAD and pancreatic beta cell function (using a glucagon stimulation test) were examined. Increased levels of antibodies to GAD (> 18 units) were detected in 12.1% (n = 17) of these subjects. Forty-three (31%) patients had a classical type 1 presentation and 65 (46%) patients were insulin-deficient based on post-glucagon plasma C-peptide levels. Patients who were insulin-deficient and had a type 1 presentation had the highest prevalence of antibodies to GAD (29.0%) compared with patients who had a type 2 presentation and were non-insulin deficient (6.4%, P = 0.003). Patients who had antibodies to GAD had lower body mass index and waist-hip ratio, earlier onset of disease, lower blood pressure, plasma triglyceride and C-peptide, and higher concentrations of plasma high-density lipoprotein cholesterol and glycated haemoglobin, and were more likely to require drug treatment, compared with those without antibodies to GAD. In conclusion, there was a low prevalence of antibodies to GAD in Chinese young diabetic patients although such antibodies remained a relatively specific marker for insulin deficiency and acute presentation. Causes other than autoimmunity should be sought to explain the high prevalence of insulin deficiency in these young Chinese patients.

Adrenal and hypophyseal non-Hodgkin's lymphoma presenting with panhypopituitarism

We report a case of non-Hodgkin's lymphoma presenting as anterior pituitary failure and found to have involvement of two endocrine glands, the pituitary and the adrenals.

Short-term efficacy and tolerability of combination therapy with lovastatin and acipimox in Chinese patients with type 2 diabetes mellitus and mixed dyslipidemia

In type 2 diabetes, it is not uncommon to find an elevated serum triglyceride and/or reduced high-density lipoprotein (HDL) cholesterol levels; elevated total cholesterol levels often occur as well. To evaluate the short-term efficacy and tolerability of combination therapy with lovastatin and acipimox in Chinese patients with type 2 diabetes who have mixed dyslipidemia, an open-label 6-month trial was conducted. All patients had type 2 diabetes (n = 33) with total cholesterol > or = 6.2 mmol/L and fasting triglyceride > or = 2.8 mmol/L, which had been confirmed twice and persisted for at least 12 weeks after introduction of diet control. After a 4-week run-in period, they were given lovastatin 40 mg daily at night for 12 weeks. Acipimox 250 mg three times a day was then added for a further 12 weeks. After 12 weeks of treatment with lovastatin alone, improvement was observed in total cholesterol (21% reduction), triglyceride (32% reduction), low-density lipoprotein (LDL) cholesterol (5.5% reduction), HDL cholesterol (11.6% elevation), apolipoprotein A-I (4.6% elevation), and apolipoprotein B (20.5% reduction). The addition of acipimox to lovastatin for an additional 12 weeks further reduced serum total cholesterol, triglyceride, LDL cholesterol, and apolipoprotein B, but this additional decrease was not statistically significant. However, HDL cholesterol and apolipoprotein A-I levels were significantly increased by the addition of acipimox (a 14.2% and 9.0% elevation, respectively). Serum creatine phosphokinase increased slightly after 12 weeks of lovastatin but decreased to a concentration similar to baseline after 12 weeks of combination treatment. No patients reported muscle pain or weakness or other side effects. Combination treatment with lovastatin and acipimox appears to be a safe and effective therapy in patients with type 2 diabetes and mixed dyslipidemia, and has particular benefit in elevating serum HDL cholesterol and apolipoprotein A-I levels.

Combined use of a fasting plasma glucose concentration and HbA1c or fructosamine predicts the likelihood of having diabetes in high-risk subjects

OBJECTIVE

To assess the validity of using fasting plasma glucose (FPG) concentrations in conjunction with HbA1c or fructosamine for the screening of diabetes in high-risk individuals.

RESEARCH DESIGN AND METHODS

In this study 2,877 Hong Kong Chinese (565 [19.6%] men; 2,312 [80.4%] women) with various risk factors for glucose intolerance underwent a 75-g oral glucose tolerance test (OGTT) for screening of diabetes. The risk factors included a family history positive for diabetes, a history of gestational diabetes or impaired glucose tolerance, and obesity.

RESULTS

Using World Health Organization (WHO) criteria, 1,593 (55.4%) had normal glucose tolerance, 657 (22.8%) had impaired glucose tolerance, and 627 (21.8%) had diabetes. When the 1997 American Diabetes Association (ADA) criteria were applied, 394 (13.7%) had diabetes with an FPG > or = 7.0 mmol/l. Using multiple receiver operating characteristic curve analysis, the paired values of an FPG of 5.6 mmol/l and a HbA1c of 5.5% gave an optimal sensitivity of 83.8% and specificity of 83.6% to predict a 2-h plasma glucose (PG) > or = 11.1 mmol/l. Likewise, the paired values of an FPG of 5.4 mmol/l and a fructosamine level of 235 mumol/l (n = 2,408) gave an optimal sensitivity of 81.5% and specificity of 83.2%. An FPG > or = 5.6 mmol/l and an HbA1c > or = 5.5% was 5.4-fold more likely to occur in diabetic subjects (based on the WHO criteria) compared with nondiabetic subjects. For paired parameters less than these values, the likelihood ratio of this occurring in diabetic subjects was only 0.11. Similarly, an FPG > or = 5.4 mmol/l and a fructosamine > or = 235 mumol/l was fivefold more likely to occur in diabetic subjects than in nondiabetic subjects, with both parameters less than these values having a likelihood ratio of 0.04. Using these paired values as initial screening tests, only subjects who had an FPG > or = 5.6 mmol/l and < 7.8 mmol/l and an HbA1c > or = 5.5% (n = 642) required an OGTT to confirm diabetes, thereby saving 77.7% [(2,877-642)/2,877] of the OGTTs performed. Similarly, only subjects who had an FPG > or = 5.4 mmol/l and < 7.8 mmol/l and a fructosamine > or = 235 mumol/l (n = 526) required OGTT to confirm diabetes, meaning that 78.2% [(2,408-526)/2,408] of the OGTTs could have been saved. Based on the 1997 ADA criterion of an FPG cutoff value of 7.0 mmol/l, the corresponding numbers of OGTTs to be saved were 82.6% and 85.5%, respectively.

CONCLUSIONS

The paired values of FPG and HbA1c or FPG and fructosamine helped to identify potentially diabetic subjects, the diagnosis of which could be further confirmed by the 75-g OGTT. Using this approach approximately 80% of OGTTs could have been saved, depending on the diagnostic cutoff value of FPG.